FORM C-233 (09/05) WHOLESALER'S MALT LIQUOR REPORT Monthly Report of Malt Liquor Received and Disposed of During the Month of: TABC USE ONLY ENTRY REG # SUMMARY **REPORT IS DUE ON OR BEFORE THE 15TH DAY OF THE MONTH FOLLOWING EACH REPORTING PERIOD** TRADE NAME: PERMIT NUMBER: ADDRESS: CITY: ZIP CODE: PHONE NUMBER: GALLONS Summary of Taxes Due (rounded off to the second decimal place) 1. Inventory, Beginning of Month (Line 4 on Prior Monthly Report) 2. Malt Liquor Received (Page 2, Line 1) 3. Total (Line 1 + 2) 4. Inventory, End of Month 5. Exemptions (Page 2, Line 2) 6. Total (Line 4 + 5) 7. Malt Liquor Subject to Tax (Line 3 - 6) $0.198 8. Tax Rate Per Gallon 9. GROSS TAXES DUE $ (Line 7 x 8) 10. LESS 2% $ (If payment is received by due date) 11. LESS AUTHORIZED CREDITS $ (Attach letter of authorization) $ 12. TAXES DUE STATE AFFIRMATION, Under penalty of perjury, I swear I am an officer or an authorized representative of the above Permittee, and I have examined this report, and confirm it is true, correct, and complete. The following box must be checked if the permittee did not purchase, sell, or possess Distilled Spirits and Wine. Other wise, Form C-210 must be filed. Signature Title Date INSTRUCTIONS: Prepare the report in duplicate, mail the original to the T.A.B.C., PO Box 13127, Austin, TX 78711-3127. Report must be filed on or before the 15th day of the month following each reporting period. Retain one copy for your files for a period of four years. As long as your permit remains active, you must file a report even if no business was conducted. Report malt liquor in terms of gallons rounded off to the second decimal place. For assistance, please contact the Compliance Department at (512) 2063342. PAGE 1 American LegalNet, Inc. www.FormsWorkflow.com TEXAS ALCOHOLIC BEVERAGE COMMISSION FORM C-233 (xx/xx) MALT LIQUOR RECEIVED - Schedule A INVOICE INVOICE SUPPLIER'S CITY / GALLONS CARRIER MAKING FREIGHT BILL DATE NUMBER TRADE NAME STATE (rounded off to the second decimal place) DELIVERY NUMBER 1. TOTAL RECEIVED (To Line 2, Page 1) MALT LIQUOR DISPOSED OF: SALES TO TEXAS DISTRIBUTORS - Schedule B SALES TO MILITARY INSTALLATIONS - Schedule C EXPORTS OUT-OF-STATE - Schedule D CARRIER CLAIMS & DESTRUCTION'S - Schedule E 2. TOTAL EXEMPTIONS (To Line 5, Page 1) NOTE: The spaces provided above for Schedules B,C,D and E should reflect monthly totals only. If more than one entry per schedule is needed, attach a supplemental schedule(s). PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com TEXAS ALCOHOLIC BEVERAGE COMMISSION SUMMARY OF MALT LIQUOR BRANDS AND PACKAGE SIZES SUBJECT TO TAX (sales to retailers ) TRADE NAME: PERMIT NUMBER: PACKAGE SIZES BRAND NAME (alphabetically) MONTH/YEAR: 1/2 bbl 1/4 bbl 24/12 can 24/12 btl TOTAL American LegalNet, Inc. www.FormsWorkflow.com